“And Four Years Later?”: How Much “Repeal” Must “Replace” Involve?
If you’re wondering why it’s taking so long for congressional Republicans to unite behind an Obamacare Replacement plan when there are several of them out there, look no further than the North Carolina U.S. Senate primary, where “Establishment” candidate Thom Tillis has incautiously said not all aspects of Obamacare are bad, yet appears to be afraid to endorse the “replacement” bill originally cosponsored by the senior senator from that state, Richard Burr. WaPo’s Greg Sargent has more:
Tillis has so far refrained from endorsing the Burr plan. And similarly, in interviews, he has claimed that of course he would replace Obamacare with something that would protect people with preexisting conditions and others who need protection, without specifying what that replacement would be. Republicans appear increasingly aware that they can’t be just for repeal, and have to promise replacements that would accomplishment some of what Obamacare accomplishes….
As the case of Tillis shows…Republicans must also simultaneously remain vague enough about those replacements so as to avoid embracing the tradeoffs they would require — since specificity there risks angering the right. Indeed, Tillis’ embrace of even some of Obamacare’s general goals has drawn fire from his primary opponent, Tea Partyer Greg Brannon.
The Coburn-Burr-Hatch proposal is dangerous politically for a primary-challenged Republican because it simultaneously embraces aspects of Obamacare (an insurance purchasing exchange, albeit one selling “deregulated”—which means less generous—products; and subsidies for purchases on those exchanges by certain low-income folk) and aspects of more conventional conservative health care thinking that are wildly disruptive of the status quo at a time when Republicans are making big hay over Obamacare “disruptions” (notably the partial rollback of the federal tax write-off for employer-based plans). Indeed, messing with employer-based coverage has been a conservative policy pet rock for years, even though GOP politicians have been leery of it since John McCain proposed junking it in 2008, and left himself exposed to a “tax increase” charge.
There simply isn’t, and can’t be, an “Obamacare replacement” proposal that lets everyone who likes the status quo keep it, while dealing with pre-existing condition exclusions, expanding coverage, and holding down costs. This is why Republicans prefer to insist they want to repeal Obamacare and are stilling “working” on a replacement, four years after enactment of the Affordable Care Act.
By: Ed Kilgore, Contributing Writer, Washington Monthly Political Animal, April 1, 2014
“A Big Flipping Deal”: Conservatives Need To Acknowledge That They’ve Lost This Battle
President Barack Obama should have skipped his Obamacare victory lap and instead let Vice President Joe Biden talk about the Affordable Care Act officially surpassing 7.1 million enrollees because achieving that milestone is – to paraphrase the colorful expression for which the vice president is well remembered – a big flipping deal.
Let’s be clear on what it’s not: It’s not a definitive number in the sense that there are many questions left to be answered which will help clarify its meaning. As a House GOP leadership aide noted to reporters after White House Press Secretary Jay Carney announced that the 7.1 million figure had indeed been surpassed, we still need to know how many of the enrollees were previously uninsured, how many have paid their premiums, how many are getting subsidies and what the age breakdown is of the enrollees.
Some of these questions are not as mysterious as many conservative critics seem to believe: The Los Angeles Times’ Noam N. Levey reported Monday, for example, that roughly one-third of the initial six million enrollees were previously uninsured and that all told 9.5 million people who hadn’t had insurance have gotten it through Obamacare; 80 percent of enrollees having paid seems to be a consensus conservative estimate; and young people reportedly made up around 27 percent of those signing on through the Obamacare exchanges, though that number may well have been higher in the final surge and was reportedly higher among those signing up in the harder-to-track private market.
And in any case, this is only the first Obamacare enrollment window; nearly twice as many people are expected to enroll in 2015 as did this year, and many more the following year. And let’s keep the full scope of the Affordable Care Act in mind as well: Obamacare numbers guru Charles Gaba estimates that altogether somewhere between 14.6 and 22.1 million people have gotten coverage under the law.
So in short, the 7 million news is not a be-all, end-all vindication of the Affordable Care Act. It is, as Bloomberg’s Megan McArdle writes, “the end of the beginning” for the law (h/t BBC’s Anthony Zurcher).
But keeping all that in mind, we also need to acknowledge another thing that it’s not: It’s not the beginning of the end.
Commentary in recent weeks and months looking toward yesterday’s deadline contemplated almost solely the scope of the next presumed Obamacare failure – whether the law would fall short of the reduced-expectations 6 million enrollee figure, let alone the original 7 million benchmark. The fact that in the end the exchanges blew by the lower figure and even exceeded the positive one, even after the bungled initial rollout of the website and more glitches on the final day of the enrollment period, is a testament to not only the fact that the law has some life in it but also the mobilization skills the administration was able to marshal in the closing weeks. (It was, if anything, reminiscent of the 2012 presidential ground game; hey now that the enrollment deadline has passed, do you think the people who masterminded getting millions of people to sign up might be available to help Democrats mobilize their notoriously somnambulant off-year voters? Just wondering.)
Republicans and conservatives, of course, are insisting that there’s nothing to see here except for fraud or failure. But the former just recalls their 2012 “unskewed” infatuation while the latter, as Steve Benen points, has them taking on an increasingly Baghad Bob-style mien. They can insist that the story of Obamacare is one of unremitting, uninterrupted failure, but who are you going to believe – Republicans or your own eyes?
Those on the right who keep trying to poke holes in the law by raising questions need to answer one they’d like to ignore: What happened to Obamacare’s inevitable collapse? Because 7.1 million enrollees is, after all, a big flipping deal.
By: Robert Schlesinger, U. S. News and World Report, April 1, 2014
“In Addition To Honesty, It Requires Accountability”: Ryan Unsuited To Lead ‘Adult Conversation’ About Poverty
These days, a favorite talking point of Republican Congressman Paul Ryan’s is calling for an “adult conversation” about poverty.
“It’s time for an adult conversation,” he told The Washington Post.
“If we actually have an adult conversation,” he said in remarks at the Brookings Institution, “I think we can make a difference.”
The problem is that a prerequisite for any adult conversation is telling the truth and it is there the congressman falls monumentally short.
In addition to Rep. Ryan’s recent, racially-coded comments about “our inner cities” where “generations of men [are] not even thinking about working,” his rhetoric around policy should raise red flags for anyone — including the media — assessing his credibility.
A report from Emily Oshima Lee, policy analyst at the Center for American Progress Action Fund, examines the hatchet job Rep. Ryan did on Medicaid in his 204-page account of antipoverty programs that The Washington Post generously described as a “critique.” Indeed, Ryan’s report — which would have been flagged by my excellent 10th grade English teacher for misrepresenting and cherry-picking data — is a dangerous disservice to a public which has neither the time nor the staff that Ryan has at his disposal to delve into literature assessing antipoverty programs.
Lee notes that Ryan misuses research to imply that Medicaid coverage leads to poorer health — that people enrolled in Medicaid will have worse health than those with private insurance and the uninsured.
“The privately insured comparison is patently unfair because these people tend to be higher income and that comes with a whole host of health privileges,” said Lee.
She notes that Medicaid enrollees tend to struggle a lot more with chronic conditions and illnesses than other populations.
“A large body of literature identifies various social determinants of health, including socioeconomic status and living and work environments, as risk factors for poor health outcomes,” writes Lee, in my opinion admirably resisting the temptation to add, “duh.”
As for the uninsured being healthier — it would be one thing if Ryan were making an “apples to apples” comparison, but he’s not.
“The uninsured is a diverse group and doesn’t only include low-income individuals. It may include people who are high-income and don’t really want insurance but can afford health services, and lower-income people who may not have previously enrolled in insurance for a number of reasons — including cost and not having any real health issues,” Lee says. “But again, to imply that Medicaid is somehow making people worse off is absurd.”
Ryan also argues that Medicaid coverage has little positive effect on enrollees’ health. But as Lee points out, Ryan conveniently overlooks studies showing an association between Medicaid and lower mortality rates; reduced low-weight births and infant and child mortality; and lower mortality for HIV-positive patients, among other heath benefits.
“In general, we need more data to accurately assess the effect of Medicaid coverage on people’s health,” Lee continues. “But several studies do indicate positive health and non-health effects of coverage — such as increased use of preventive care and greater financial security.”
Rep. Ryan also plays on fears of low-income people abusing the welfare system when he asserts that Medicaid coverage improperly increases enrollees’ use of health care services, including preventive care and emergency department services. Ryan makes this case too by comparing Medicaid enrollees to uninsured people, who, as Lee writes, “are less likely to use health care services due to significant financial barriers.”
“Presenting data that Medicaid enrollees use more health services than the uninsured affirms that insurance coverage allows people who need care to seek it out,” writes Lee, “and that being uninsured is a major barrier to receiving important medical care.”
Further, one of the two studies Ryan references explicitly states that “neither theory nor existing evidence provides a definitive answer to… whether we should expect increases or decreases in emergency-department use when Medicaid expands.”
Despite Ryan’s shabby work when it comes to antipoverty policy, the media repeatedly seems willing to overlook it. That’s another strike against the prospects of a truly adult conversation about poverty — in addition to honesty, it requires accountability.
By: Greg Kaufmann, Moyers and Company, Bill Moyers Blog, March 29, 2014
“Reality Is Starting To Set In”: Is The “Mend It” Period Of The Affordable Care Act’s Evolution Beginning?
All of a sudden, people in Washington seem to want to fix the Affordable Care Act. And regardless of their motivations, that should be—well, maybe “celebrated” is too strong a word, but we can see it as a necessary and positive development. Is it possible that the arguments about whether the ACA was a good idea or should have been passed in the first place are actually going to fade away, and we can get down to the businesses of strengthening the parts of it that are working and fixing the parts that aren’t? It might be so.
Sure, cretinous congressional candidates will continue to display their seriousness by pumping paper copies of the law with bullets, probably for years to come. But with this year’s open enrollment period coming to an end in a few days, a particular reality is starting to set in, namely that, however you feel about the law, millions of Americans have now gotten health insurance because of it. Repealing it would mean taking that insurance away. So let’s look at what people whose political fortunes are dependent on some measure of anti-ACA grandstanding are doing.
First, a group of centrist Democrats, mostly from conservative states, offered a plan to make some changes to the ACA, some of which are more meaningful and reasonable than others. Yes, they’re doing it because they want to give themselves some political cover. But that’s OK. Meanwhile, some Republicans are, for the umpteenth time, crafting a package of things they claim will “replace” the ACA. Of course it’s the same few things they’ve always advocated—make it impossible for people to sue for medical malpractice (AKA “tort reform”), let people buy insurance across state lines, encourage health savings accounts. Nobody who has thought about health care for five minutes thinks those “reforms” would do anything to address real health care challenges, but more importantly, they wouldn’t prevent the massive upheaval that would occur if you repealed the ACA. And that’s a reality that will become increasingly clear: the disruption of taking away the ACA now would be even greater than the disruption the law brought about in the first place.
So if Republicans took over the Senate, there would be a brief period of kabuki, in which they would attempt to pass their reform package, then President Obama would say, “This is a joke” and veto if it passed. Then they’d have to decide if they actually wanted to address their specific complaints about the ACA. And yes, we have to start from the assumption that everything conservatives say about the Affordable Care Act is offered in bad faith (sorry, conservatives, but you’ve earned it). That doesn’t mean, however, that they can’t prove that assumption wrong at some later date.
Democrats should respond by welcoming a more particular debate about the ACA, starting from the presumption that it’s law now and millions of people are dependent on it, so the question is what needs adjustment. Republicans can no longer just shout “This law sucks, because freedom!” It’s too late for that.
And some context is in order. Before the law was even passed, many of its advocates were careful to note that no matter how much care went into its design, adjustments were going to be required as it was implemented. That’s how things always go with complicated laws: conditions change, certain features don’t work the way they were supposed to, and unforeseen challenges emerge. Revising existing legislation is a substantial part of lawmaking, and always has been. For instance, when Social Security was created in 1935, it was written to exclude agricultural and domestic workers, which included most blacks in the South (there’s some debate about whether this was actually done in order to secure the support of Southern segregationists). That didn’t change until the 1950s. Survivor benefits for spouses and children were also added later. Cost of living adjustments were added later. In other words, the most successful and popular social program in American history required a lot of changes and alterations as it evolved, and no one ever expected that the ACA would be any different.
There are going to be changes to the ACA in the coming years, just as there should be. The trick now will be making sure the right changes are made.
By: Paul Waldman, Contributing Editor, The American Prospect, March 28, 2014
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